NORTH SYDNEY COUNCIL

IMMUNISATION REGISTRATION

CHILDS DETAILS
Family Name: Date of Birth: Address Given Names: Gender: Male Female

Street address

Suburb

Postcode

Medicare Card Number:

Child Medicare Reference no:

1/2/3/4/5/6

PARENT/GUARDIANS DETAILS
Family Name: Relationship to Child: Home Phone: Emergency Contact Name: Given Name: Please circle: Alternate Phone: Emergency Contact Phone: Mr / Mrs / Ms / Other

________
Mobile / Work

Mobile / Work

I, _______________________________________________________________ (parent/guardian name) having read

(please print)

and understood the information on the risks and benefits of vaccination, do hereby give consent for the child, ____________________________________________ (name) to be vaccinated with the vaccines as indicated on (please print) the N.I.P. Schedule. Signature: __________________________________________________________ Date: ____/____/____

Either fax, post or bring the completed form to the next immunisation clinic Fax: 9936 8177 Post: North Sydney Council, PO Box 12, North Sydney 2059 For further information contact the Immunisation Co-ordinator on (02) 9936 8100.

Health Records and Information Privacy (HRIP) Act In completing this form you will be prompted to supply information that is personal information for the purposes of the Health Records and Information Privacy (HRIP) Act, 2002. The supply of this information is voluntary. If you cannot provide, or do not wish to provide the information sought, North Sydney Council may be unable to process your request. Council is required under the Act to inform you about how your personal information is being collected and used. If you require further information please contact Councils Customer Service Centre on (02) 9936 8100 and ask for an information sheet to be sent to you.

INTERPRETER REQUIRED?

YES

NO

LANGUAGE: ________________________________ YES NO

ABORIGINE OR TORRES STRAIT ISLANDER?

Record of immunisation history on page overleaf to be filled in by immunisation clinic co-ordinator at first clinic

Ph:

9936 8100

Fax:

9936 8177

Email:

council@northsydney.nsw.gov.au

01/07/10

NORTH SYDNEY COUNCIL

IMMUNISATION DETAILS

OFFICE USE ONLY: Details of Immunisations Administered

KEY DETAILS
Childs Name: Medicare Card Number: Date of Birth: Child Medicare Reference no: Dose 1 Date given Hepatitis B (at birth) Infanrix Hexa - Diphtheria, Tetanus, Pertussis - Haemophilus influenzae type B (Hib) - Hepatitis B - Polio Prevenar (Pneumococcal) Rotarix (oral) (Rotavirus) Priorix (Measles, Mumps, Rubella) Hiberix (Hib) Meningitec (Meningococcal C) Varilrix (Varicella Chicken Pox) Infanrix-IPV - Diphtheria, Tetanus, Pertussis - Polio Other Other Other Other Other Other Other Consent (or provider details) Dose 2 Date given Consent (or provider details) Dose 3 Date given Consent (or provider details)

Vaccine (diseases listed)

Ph:

9936 8100

Fax:

9936 8177

Email:

council@northsydney.nsw.gov.au

01/07/10